Ensuring Health Care Equity in Ethiopia

Although Ethiopia’s health care is grounded in equity principles and health outcomes have shown considerable improvements during the past 20 years, substantial challenges persist. Indeed, though equal access to essential health services for those in equal need has been largely ensured, equal utilization of health care for them and equal health outcomes have not been attained yet. Systematic disparities in the burden of diseases, service uptake and health outcomes prevail between communities, particularly arising from differences in places of residence. In the face of this, a range of diverse initiatives have been taken by the Ministry of Health to mend the chasm in health service uptake and health outcomes between the regions

Taye Balcha

by Taye Tolera Balcha

Head, Office of the State Minister

Ministry of Health, Ethiopia

Ensuring Health Care Equity in Ethiopia


With a little less than 100 million people, Ethiopia is the second most populous country in Africa. About 80% of Ethiopia’s population live in the rural part of the country. While an overwhelming majority of rural residents live on agriculture, 10% of the population living in the Eastern and South Eastern parts of the country are pastoralists. Generally, pastoralist parts of the country are sparsely populated. Ethiopia is one of the fastest growing economies in the world. The World Bank predicts that Ethiopia will be a middle-income country by 2025.

Health outcomes in Ethiopia have shown considerable improvements during the past 20 years. A sharp rise in the life expectancy at birth from 46.7 in 1990 to 65 years to date shows a significant leap in the aggregate picture. The child mortality rate, which had been 204 per 1,000 live births in 1990 dropped to 62 per 1,000 live births in 2014. Between 1990 and 2014, maternal mortality declined by 72%. Both international and national targets set for health have been met. In particular, Ethiopia achieved all health Millennium Development Goals (MDGs).

Ethiopia chalks up its success to an equity-based primary health care. In 2003, the country introduced a signature primary health care- Health Extension Programme (HEP). By design, the HEP combines the overall capacity of the country with community contexts and needs. With low cost for the nation and prominent community participation, a health post has been constructed in each village across the country. To address social and basic health intervention demands of the community, an army of female community health workers – Health Extension Workers (HEWs) – have been recruited, trained and assigned to the health posts. Paid by the government, the chief responsibility of the HEWs (usually 2 or more at each health post) is to provide culture-sensitive package of health promotion, disease prevention and essential curative health services. Interventions targeting maternal and child conditions and infectious diseases stand out in the set of services provided at primary health care level. The recruitment of HEWs from the community they eventually serve is instrumental in providing sustained, community-desired and individually-preferred services at each health post. For instance, HEWs can provide oral contraceptive pills, injectables or implants for family planning depending on the women’s choice.

The HEP is particularly an enormous success in the agrarian parts of the country. Over the past decade, the HEWs have graduated millions of model households (those who utilize all community level health interventions they are eligible for). As a consequence, improvement in health literacy and an upsurge in community-based service uptake have been reported. Recently, the HEWs trained women development groups in each village to advance the community engagement in and ownership of their health. This resulted in organized communities that demand and enthusiastically contribute to improved essential health services. This further catalysed the rising service uptake including utilization of family planning, skilled birth attendance, immunization, nutrition services and construction and use of improved latrines. The effectiveness of initiatives of health promotion and disease prevention targeting major communicable diseases including tuberculosis, HIV and malaria has shown considerable improvement. Bolstered by the growing impacts of the community in improving health, Ethiopia has planned to transition the concept of model households to model villages. Similar to model households, to be categorized as model villages, entire member residents of the village should utilize all key community level health interventions. Additionally, model villages should be represented in health facility governance at each level of care to foster accountability and continuous quality improvement. The metrics used in model village evaluation and categorization largely focus on an individual member of the village rather than aggregate village or district picture to eliminate disparities in service utilization within a specific community.

Higher levels of health care have received adequate emphasis. Thousands of health centres have been constructed across the country, one for 25,000 people or less. Owing to the rising public expectations, massive construction of primary hospitals is underway for some time to achieve the target of 1 primary hospital for 100,000 population. Equity-centred distributions of zonal and specialized referral hospitals complete the spectrum of health care in the country. Concurrent investment has been made into the development of human resources for health. The number of public medical schools has jumped from a paltry 3 in 2004 to 34 in 2015. Currently, more than 3,000 medical doctors graduate annually compared with about one hundred, eventually overworked doctors a decade ago. Likewise, training of other cadres including specialized nurses, mid-wives, integrated emergency surgical officers and public health officers has been fast-tracked to fully staff the growing number of health facilities. The construction of health facilities and assignment of health staff to each region in the country is guided by an equity-sensitive ratio, nationally endorsed by Ethiopia’s House of Federation for allocation of all types of resources.

Although Ethiopia’s health care is grounded in equity principles, substantial challenges persist. Most notably, equal access to essential health services for those in equal need has been largely ensured. Yet, equal utilization of health care for those in equal need and equal health outcomes have not been attained. Systematic disparities in the burden of diseases, service uptake and health outcomes prevail between communities, particularly arising from differences in places of residence. For instance, in 2012, the HIV prevalence ranges from 0.9% in the Southern Nations, Nationalities and Peoples region (SNNPR) to 6.5% in Gambella region. The proportion of children younger than one year who received their full immunizations in 2015 is 34% and 98% in Ethiopia Somali region and SNNPR, respectively. In 2011, child mortality rate substantially varied between 53 per 1,000 live births in Addis Ababa and 169 per 1,000 live births in Benishangul Gumuz region. In general, the two pastoralist regions in the Eastern part of the country (Afar and Ethiopia Somali) and the two regions in the western part of the country (Gambella and Benishangul Gumuz) are worse-off in service uptake and health outcomes than every other region in the country.

The current geographical inequities in health care in Ethiopia is mainly attributed to inadequate implementation capacity and deficiencies in the health systems in the pastoralist and in the regions located in the extreme west of the country. The Ministry of Health has taken a range of diverse initiatives to mend the avoidable chasm in health service uptake and health outcomes between the regions.  The ratios of HEWs, health posts and health centres to the population have been adjusted upward to address the remaining barriers in regards to access to essential health services. Mobile clinics are providing essential clinical services in selected districts of the pastoralist regions along pasture and water points for their cattle to tailor the health service to the lifestyle of the community, and thus boost the service uptake. To strengthen the health systems in these 4 regions, a Health Systems Special Support Directorate is designated at the Ministry. The directorate provides an intensive systems support to these regions. Furthermore, the Ministry is currently hiring dozens of senior public health specialists to be based at each region and galvanize the health systems, and thus the performance of each health facility. Salaried by the Ministry, a mix of public health and clinical officers are also placed at selected districts to beef up the implementation capacities of the districts. Differential support in regards to ambulance services, an array of public health and clinical interventions including maternal and child health and major communicable diseases (malaria, tuberculosis and HIV) prevention and control, and heightened overall support has been provided to these regions.

Ethiopia’s Health Sector Transformation Plan (2015-2020) boldly states that all health indicators in these regions should rise to the level of the national average within the next 5 years. These targets are overly ambitious. Equally notable, the commitment of the government to holding down health inequities arising from differences from personal or community characteristics is unprecedented. More specifically, the health sector has embarked on multi-layer equity insuring interventions: authentic community engagement in health in all regions, provision of tailored health services and health systems overhaul in the societies and geographies left behind. The 5 year health sector transformation plan also highlights the need for progressive evaluations of barriers to healthy behaviours and subsequent implementation of equity-targeted social, public health and clinical interventions. Socio-economic factors fostering service uptake will be assessed and encouraged regularly; a detailed, right-based scrutiny will be performed on unreached individuals and populations; and bi-annual status of inequality report will be produced and disseminated. Innovations that could improve the health status in the four regions will be stimulated; and innovations with promise for population level impact will be transitioned to investment at regional scale. Most importantly, the government just transitioned community-based health insurance (targeting citizens engaged in informal sector) from a learning phase to a national scheme. Employees of formal sector are planned to be fully covered in 2016 through social health insurance.  The two insurance schemes are expected to completely remove financial barriers to health care and enhance care seeking behaviour.

In conclusion, Ethiopia is determined to ensure equitable access to essential health services. This can be done through intensifying differential systems support to the group left behind. The local health leadership in the regions and the general health workers should fully comprehend the prevailing equity challenges and work towards rooting them out. Initiatives explicitly targeting the unreached populations will be implemented. The sheer power of partnership with community to ensure equitable access to good health should be recognized. The new initiatives including health insurance schemes will contribute to attaining better health for all citizens living in all geographies of Ethiopia.